HomeMy Public PortalAbout4700 F MILLER DR_Plumbing__ r`, �• "`WORKERS'COMPS:.JSAT.IOTv`DECLARATION: APPLICAT'I'ON FOR PLUMBING PERMIT
I.hereby, dfirm'that 1'have a+certificate of consent to self in= 76A667A 0-,0026 DPW 4/87 n
".sure,or crcertificate•of Workers'Compensation Insurance,or a ,ul
P CE 817(REV.8786•) ,
certified"copy thereof (gec. 3800, Lab. C..)
COUNTY OF LOS ANGELES DEPT. OF.PUBLIC WORKS'
.Policy..No�°n—D44R9•Cin4Company.C= Tn��
�. Certified copy is hereby furnished.
FOR/APPLICANT TO FILL I.N(PRINT OR TYPE) BUILDING
Certified copy is filed with the-county building inspection ADDRESS f(JJ 'C.Irwwn
department. NUMBER, FIXTURE OR ITEM @ FEE LOCALITY
WATER CLOSET(TOILET) •.�
Date 6-21-91 ,Applicant GkTerBMS-1 21-mb NEAREST
ATH TUB. la�� ) •.•;( CROSS ST. "a.y e'1,. •L
CERTIFICATE OF EXEMPTION FROM WORKERS'•• aB.
COMPENSATION INSURANCE OWNER
SHOWER
(Thi's section need not be completed if the work involved by MAIL
the permit is for one hundred dollars($100)or less.) LAVATORY ADDRES$2031 S.
I certify that in the performance of the work forwhich-this per- SINK CITY TEL. NO.
mit is issued, I shall not employ any person in any manner so
as to become subject to the Workers'Compensation Laws:- DISHW.ASHER —
CONTRACTOR
Date Applicant CLOTHES WASHER
NOTICE TO APPLICANT: If, after,making this Certificate of Ex- ' ,4DDRESS 42.65 N... BaldWih Avenue
f•ion,you should become subject to the Workers'Com en- SWIMMING POOL RECEPTOR
em
P Y I P CITY - TEL:NO.
sation'provisions of the Labor Code,you must forthwith comp.- LAWN SPRINKLER SYSTEM
ly with such provisions•or this permit shall be deemed revok- STATE LIC. —
%DV 78
ed. WATER HEATER• /'] •.LICENSE NO.' • CLASS _
LICENSED-CONTRACTORS DECLARATION ; 6/ DISTRICT NO. PROCESSED BY
I'hereby.affirm that I am licensed under provisions of Chapter . GAS SYSTEM OUTLETS ( �r
9,(commencing with Section.7000)of Division 3 of-the Business., OUTLETS OVER
d
and Professions Code, and my license;is•in full force and ef- 5 PER SYSTEM FINAL VALIDATION
fect. I O.
DATE G )II O
License Number 231% 741 Lie...Clast362046 0
FINAL
Ower' Bros Pfimb. 6-21-91 B.Y O
Contractor Date
0 I am exdmpf-under Sec.. _..
B'.&P.C. for this reasonPlan Check fee N
Date: PLUMBING PERMIT ISSUING FEE.$ (�
.Signa'tu're-
TOTAL FEE
SINGLE FAMILYo
HOME OWNER-BUILDER DECLARATION Plan cheek applicant 5
1 hereby affirm that I am exempt from the Contractor's License Name :�
Law for the following reason (Section 703.1.5, Business and. ACCT AT
Professions Code): Address• r "
33. 10
El
I, as owner of the property, will do the work and the City Tel. No. i TT EMS
,structure is not intended or offered for sale(Section 7044; -
Business and Professions Code
CONSTRUCTION LENDING AGENCY ® GHLi;KtSIJaLS
1 hereby affirm that there is.a construction lending agency for -
the•performance of the work for which this permit is issued CHANGE .0,%.
(Sec. 3097, Civ. C.). '
Lender's Name.
- 6,124:':
Lender's Address 7653 1 Arl 9.04
I certify that I have read this application and state that the
above information is correct. I agree to comply with all County
"bove-mentlbAned
State laws regulating Plumbing, and hereby
entatives-of this County to enter upon the.,
property for inspection purposes.
_21-91 - 1 SEE REVERSE FOR EXPLANATORY LANGUAGE
49 mittee Date